Provider Demographics
NPI:1104895705
Name:ROTH, JAMES T (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:T
Last Name:ROTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1441 NE 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661-5420
Mailing Address - Country:US
Mailing Address - Phone:208-642-9376
Mailing Address - Fax:208-642-9598
Practice Address - Street 1:1219 SW 4TH AVE UNIT 2
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-4500
Practice Address - Country:US
Practice Address - Phone:801-261-3975
Practice Address - Fax:801-262-9142
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT263690-1205207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTF60020Medicare UPIN